What is the management approach for a patient with elevated lactate levels and suspected sepsis or septic shock?

From the Guidelines

Management of a patient with elevated lactate levels and suspected sepsis or septic shock requires immediate implementation of the Surviving Sepsis Campaign's guidelines, which include measuring lactate levels, obtaining blood cultures, administering broad-spectrum antibiotics, and starting rapid intravenous crystalloid resuscitation with 30 ml/kg of balanced crystalloids for hypotension or lactate ≥4 mmol/L 1.

Key Components of Management

• Measuring lactate levels and obtaining blood cultures before antibiotics
• Administering broad-spectrum antibiotics
• Starting rapid intravenous crystalloid resuscitation with 30 ml/kg of balanced crystalloids for hypotension or lactate ≥4 mmol/L
• Applying vasopressors if hypotension persists during or after fluid resuscitation, with norepinephrine as the first-choice vasopressor, typically started at 0.05-0.1 mcg/kg/min and titrated to maintain a mean arterial pressure of ≥65 mmHg 1
• Remasuring lactate within 2-4 hours if initially elevated

Ongoing Management

• Source control (identifying and addressing the infection source)
• Reassessing antibiotic therapy within 48-72 hours based on culture results
• Providing supportive care Elevated lactate indicates tissue hypoperfusion and anaerobic metabolism, serving as both a diagnostic marker and a guide for resuscitation effectiveness 1. Rapid intervention is critical as each hour of delay in appropriate antibiotic therapy increases mortality by approximately 7-8% in septic shock patients.

Guiding Resuscitation

• Guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion 1
• Using dynamic over static variables to predict fluid responsiveness, where available 1

From the FDA Drug Label

LEVOPHED should not be given to patients who are hypotensive from blood volume deficits except as an emergency measure to maintain coronary and cerebral artery perfusion until blood volume replacement therapy can be completed If LEVOPHED is continuously administered to maintain blood pressure in the absence of blood volume replacement, the following may occur: severe peripheral and visceral vasoconstriction, decreased renal perfusion and urine output, poor systemic blood flow despite "normal" blood pressure, tissue hypoxia, and lactate acidosis Prolonged administration of any potent vasopressor may result in plasma volume depletion which should be continuously corrected by appropriate fluid and electrolyte replacement therapy If plasma volumes are not corrected, hypotension may recur when LEVOPHED is discontinued, or blood pressure may be maintained at the risk of severe peripheral and visceral vasoconstriction (e.g., decreased renal perfusion) with diminution in blood flow and tissue perfusion with subsequent tissue hypoxia and lactic acidosis and possible ischemic injury.

The management approach for a patient with elevated lactate levels and suspected sepsis or septic shock involves fluid and electrolyte replacement therapy to correct plasma volume depletion, as well as careful consideration of the use of vasopressors like norepinephrine, to avoid exacerbating tissue hypoxia and lactic acidosis 2, 2.

• Key considerations include maintaining adequate blood volume and perfusion to prevent tissue hypoxia and ischemic injury.
• Monitoring for signs of severe peripheral and visceral vasoconstriction, decreased renal perfusion, and tissue hypoxia is crucial.

From the Research

Management Approach for Elevated Lactate Levels and Suspected Sepsis or Septic Shock

• The management of patients with elevated lactate levels and suspected sepsis or septic shock involves a comprehensive approach, including fluid resuscitation, vasopressor support, and addressing the underlying cause of lactate elevation 3.
• Lactate levels can be elevated due to various reasons, including tissue hypoperfusion, sepsis, cardiac arrest, trauma, and medication-related causes 3.
• The use of lactated Ringer's solution for initial fluid resuscitation may be associated with improved clinical outcomes, including lower incidences of hyperlactacidemia and hyperchloremia, compared to normal saline 4, 5.
• Norepinephrine is the first-line vasopressor of choice for septic shock, and its dosage may indicate the severity of vasoplegia and oxygen metabolism disorder 6, 7.
• The management approach should be tailored to the underlying cause of lactate elevation, and clinicians should be aware of the potential causes and contributing factors to lactate level elevation 3.

Fluid Resuscitation and Vasopressor Support

• Fluid resuscitation is a critical component of the management approach, and the choice of fluid may impact clinical outcomes 4, 5.
• Lactated Ringer's solution may be preferred over normal saline for initial fluid resuscitation due to its potential to reduce hyperlactacidemia and hyperchloremia 4, 5.
• Norepinephrine dosage may be associated with lactate clearance, and higher doses may indicate more severe vasoplegia and oxygen metabolism disorder 6.
• Vasopressor support should be tailored to the individual patient's needs, and clinicians should be aware of the potential side effects and interactions of vasoactive agents 7.

Monitoring and Adjunctive Therapies

• Close monitoring of lactate levels, hemodynamic variables, and clinical outcomes is essential to guide the management approach 3, 6.
• Adjunctive therapies, such as antimicrobial therapy and supportive care, should be tailored to the underlying cause of sepsis or septic shock 3, 7.
• Clinicians should be aware of the potential benefits and limitations of lactate as a diagnostic and prognostic tool, and its potential use as a clinical endpoint of resuscitation 3.